REMOTE DERMATOLOGY SERVICE – FOR NEW PATIENTS

Welcome to Rao Dermatology, where as a new patient you will soon be evaluated for your skin-related problem, and a personalized management plan will be created and implemented for you. Our goal is to help you achieve effective and timely improvement in a safe manner.

In these uncertain times of the COVID-19 pandemic, social distancing is key to maintaining health and safety. Although our office is presently closed to limit contact with others, we are pleased to offer you our novel Remote Dermatology Service, reducing the need to visit us in-person. To qualify you must have a doctor’s referral already sent to us. If this is not the case, please ask your doctor to fax in a referral to: 780-437-2247.

If you already have a doctor’s referral pending, please fill out the secure form below. You will be contacted shortly by the Rao Dermatology Team. Based on our assessment of what you provide to us, we will arrange for one of the following:

a remote session with you, or
a face-to-face session with you

We are continuing to monitor the situation, and are taking all necessary precautions to do our part to limit the spread of COVID-19. We thank you for your patience. Be safe and healthy.

Rao Dermatology Team

REMOTE DERMATOLOGY FORM:

I am a patient of...

Please choose from the list of doctors below:

Administrative Information

If this form being completed by a Guardian/caregiver, please provide full name and contact information.

Guardian’s/Caregiver’s Full Legal Name:

Association to the Patient:

Patient’s Full Legal Name*:

Date of Birth*:

Gender*:

MaleFemale

Alberta Healthcare Number*:

Preferred Email*:

Preferred Phone Number*:

Current Problem

What is the skin-related condition we are treating? Describe as much as possible.

How long has the problem been present?

What current medication(s) are you using to treat the problem?

What past medications did you use to treat the problem?

What other oral medications are you taking (for other conditions)?

Do you have allergies to any medications?

Other notes:

Pharmacy Information

Pharmacy Name:

Pharmacy Location:

Pharmacy Telephone Number:

Pharmacy Fax Number:

Digital Image of the Current Problem

If you have issues uploading your images in the provided fields, please email attachments via email to newtelederm@raoderm.com with a subject line: "Telederm: New Patient - [Your Full Name]".

(NB: Scan or image must be under 8MB)

Carefully select the image you wish to submit:

Statement of Authenticity

Statement of Authenticity*:

The information provided above is accurate, and I understand that missing or incorrect information will result in my teledermatology request NOT being answered, for it jeopardizes health and poses medico-legal liability.

Lead status